Education and learning
Postgrad Med J: first published as 10.1136/postgradmedj-2020-137840 on 13 May 2020. Downloaded from http://pmj.bmj.com/ on May 13, 2020 at Uppsala Universitet BIBSAM Consortia.
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1
Department of Obstetrics
and Gynaecology, National
University Hospital, Singapore
2
Department of Cardiology,
National University Heart
Centre, Singapore
3
Department of Medicine,
Yong Loo Lin School of
Medicine, National University of
Singapore, Singapore
4
Department of Anaesthesia,
National University Hospital,
Singapore
5
Centre for Medical Education,
Yong Loo Lin School of
Medicine, National University of
Singapore, Singapore
6
Emergency Medicine
Department, National University
Hospital, Singapore
7
Department of Surgery, Yong
Loo Lin School of Medicine,
National University of
Singapore, Singapore
Correspondence to
Dr Abhiram Kanneganti,
Department of Obstetrics
and Gynaecology, National
University Hospital, Singapore
119074, Singapore;
​abhiram_​kanneganti@​nuhs.​
edu.s​ g
Received 7 April 2020
Accepted 11 April 2020
© Author(s) (or their
employer(s)) 2020. No
commercial re-­use. See rights
and permissions. Published
by BMJ.
To cite: Kanneganti A, Sia
C-­H, Ashokka B, et al.
Postgrad Med J Epub ahead
of print: [please include Day
Month Year]. doi:10.1136/
postgradmedj-2020-137840
Continuing medical education during a pandemic: an
academic institution’s experience
Abhiram Kanneganti ‍ ‍ ,1 Ching-­Hui Sia,2,3 Balakrishnan Ashokka ‍
Shirley Beng Suat Ooi6,7
Abstract
The COVID-19 pandemic has affected healthcare
systems worldwide. The disruption to hospital routines
has affected continuing medical education (CME)
for specialty trainees (STs). We share our academic
institution’s experience in mitigating the disruption
on the CME programme amidst the pandemic.
Most specialty training programmes had switched
to videoconferencing to maintain teaching. Some
programmes also utilized small group teachings with
precautions and e-­learning modules. Surgical residencies
were disproportionately affected due to reductions in
elective procedures but some ways to provide continued
surgical exposure include going through archived surgical
videos with technical pointers from experienced faculty
and usage of surgical simulators . We should adapt CME
sessions to keep trainees up to date with core clinical
competencies as they will continue to manage both
COVID-19 and non-­COVID-19 cases and this pandemic
may last until year’s end.
Since February 2020, COVID-19 has infected more
than a million people and taken almost 50 000 lives
with 50 000 cases and 5000 deaths in the UK alone.
It has overwhelmed healthcare systems across the
world with several countries instituting nationwide
lockdowns, border controls and social distancing
measures to curb spread. In the UK and several other
countries, final year medical students are being fast-­
tracked to serve on the front lines.1 For Singapore,
this is reminiscent of the severe acute respiratory
syndrome (SARS) outbreak of 2003 where 238 were
infected and 33 died. Then, decisive leadership mini-
mised casualty count through a systematic process
of hospital containment, rigorous surveillance and
isolation, wide-­ spread community temperature
screening, border controls, closure of schools and
public engagement.2 A major strategy in ensuring
continuity of healthcare services included segregating
healthcare professionals (HCPs) into teams divided
by time, place and skillset. Resultant increases in
manpower and service needs coupled with the
avoidance for congregation meant that all non-­time-­
critical administrative and training functions ceased.
Training for specialty trainees (STs) were casualties
and were neglected for the 6 months the outbreak
raged with medical education both in Singapore3 and
globally4–7 suffered. Lessons were learned with three
key understandings: (1) pandemics can be prolonged,
(2) high-­quality non-­pandemic medical care is still a
priority and (3) disruption to various functions can
be reduced through technology.
Kanneganti A, et al. Postgrad Med J 2020;0:1–3. doi:10.1136/postgradmedj-2020-137840
‍ ,4,5
Continuing medical education (CME) refers to
structured, scheduled sessions directed toward all
STs within a specialty training programme. They
promote the upkeep of clinical skills and knowl-
edge, maintain performance and ensure good
patient outcomes8 and are thus crucial in enabling
STs to continue delivering high-­ quality patient
care. With this pandemic likely to last until this
year’s end, we need to keep our STs equipped to
deal with the continual non-­COVID-19 cases and
ready to face an ever-­growing set of unmet clin-
ical needs that are being postponed so we can deal
with the current crisis. As our STs are on the front
lines, it is important not to ignore their training.
Just as various companies are innovating with work
from home methods, it may be worthwhile to use
technology to innovate and find ways to continue
training.
Protected by copyright.
The first COVID-19 case in Singapore was
detected on 23 January 2020. By 7 February 2020,
Singapore had 33 cases and escalated her pandemic
alert to the penultimate level of Disease Outbreak
Response System Condition (DORSCON)-­Orange.
Similar restrictive measures to the SARS outbreak9
were instituted with a return to HCP team segre-
gation once again. Immediately, traditional didactic
and small-­group ST teachings were discontinued.
The National University Hospital (NUH), Singa-
pore is a tertiary academic medical institution
and is host to 32 specialty training programmes
(table 1). Several of our training programme direc-
tors and educational supervisors had experienced
the SARS outbreak first-­ hand and were aware
that this pandemic would be prolonged. Once the
ground had settled, it was important to resume
CME to equip our STs with the skills to manage
both COVID-19 and non-­COVID-19 cases. In the
past decade, the development of user-­friendly and
accessible videoconferencing applications coupled
with the widespread usage of smartphones and
nationwide stability of 4G networks have made
videoconferencing an effective option in tran-
siting postgraduate medical education to virtual
platforms.
Of the 32 training programmes, 75% had to
discontinue their CME programmes immediately
once DORSCON-­Orange was announced as they
adjusted to this new working environment. Within
the first 2 weeks, about 45% of training programmes
had managed to restructure and resume sustained
CME programmes. This increased to 70% by 4
weeks and 85% at the end of 8 weeks. Of the 27
training programmes that have successfully resumed
1
 Education and learning

Postgrad Med J: first published as 10.1136/postgradmedj-2020-137840 on 13 May 2020. Downloaded from http://pmj.bmj.com/ on May 13, 2020 at Uppsala Universitet BIBSAM Consortia.
five training programmes that have not yet resumed regular
Table 1 Thirty-­two specialty training programmes at the National
CME sessions are small and resultantly have a very high degree
University Hospital, Singapore, as well as different methods taken to
of interaction between the STs and their educational super-
ensure the continuation of continuing medical education in each of
visors. They are taking active steps toward creating specialty-­
them
specific CME programmes which will come online in the next
Specialty training programmes Methods used few weeks. Nevertheless, increased service needs and dyssyn-
Medical chronous rosters have caused 35% of training programmes to
1. Internal Medicine Videoconferencing continue CME sessions at a reduced frequency to cope in this
2. Endocrinology new operating environment. This highlights that even though
3. Nephrology videoconferencing can be used to continue CME, it would
4. Infectious Diseases understandably have to compete and coexist with the signifi-
5. Respiratory and Critical cantly higher clinical priorities of the day that is, this pandemic.
Care Respiratory Medicine, Preventive Medicine, Emergency
6. Neurology Medicine and Infectious Diseases STs are deeply involved in this
7. Gastroenterology pandemic. Respiratory Medicine had been able to restart their
8. Rheumatology CME programme within 2 weeks, while Emergency Medicine
9. Medical Oncology
and Infectious Diseases took about 6 weeks as the rapidly evolving
COVID-19 situation necessitated an urgent need to develop
10. Haematology
protocols and redistribute manpower. Preventive Medicine STs
11. Cardiology
were dispersed early on to various bodies to assist with pandemic
12. Dermatology
management and so they replaced their formal CME programme
13. Geriatrics
to one which was more mobile phone-­based and tailored to sharing
14. Paediatrics
the latest updates, literature and guidelines on COVID-19.
15. Family Medicine Other disciplines have taken different approaches. Psychiatry
16. Preventive Medicine Mobile-­phone based regular updates continue to have small-­group teachings among two to three STs
17. Psychiatry ►► Videoconferencing with appropriate physical distancing in addition to videoconfer-
►► Small-­group didactics with adequate encing, which is appropriate given their small ST cohort size and a
social distancing
need for in-­person mental state examinations. Disciplines dealing

Protected by copyright.
Surgical
with oncology such as Medical Oncology, Pathology, Radiology
18. General Surgery ►► Videoconferencing and surgical specialties traditionally included multidisciplinary
19. Orthopaedics ►► Surgical videos
►► Surgical simulators
tumour board sessions as part of their CME. Tumour boards had
20. Hand Surgery already been using videoconferencing prepandemic and oncolog-
21. Cardiothoracic Surgery ical work needed to be continued given its time-­critical nature. As
22. Neurosurgery a result, CMEs through tumour boards continued without disrup-
23. Obstetrics and tion and transited effortlessly into a fully virtual environment.
Gynaecology Non-­oncological elective surgical work has been reduced by 80%
24. Urology to reserve surge capacity for critical care and other resources. As a
25. Paediatric Surgery result, surgical training programmes have been disproportionately
26. Plastic Surgery affected by a reduction of hands-­on training opportunities. Usage
27. Otorhinolaryngology of in-­house surgical simulators are being reviewed to address this
28. Ophthalmology shortfall. Videoconferencing has been successfully used in surgical
Others education10 and Obstetrics and Gynaecology uses recorded surgical
29. Anaesthesia Videoconferencing videos to go through anatomical and surgical principles.
30. Pathology Videoconferencing Several colleges have also postponed important milestone
31. Radiology Videoconferencing examination.11 This is a source of great distress to any ST as
32. Emergency Medicine ►► Videoconferencing
many life decisions are frequently put on hold and significant
►► Small-­group didactics with adequate effort goes into staying prepared. While multiple-­choice ques-
social distancing tions can be practised with question books, Objective Structured
►► Procedural videos Clinical Examination (OSCE) require rehearsal with live partic-
ipants. OSCEs involving simulated patient encounters and topic
discussion have been conducted over videoconferencing success-
their CME programmes, all have switched to videoconferencing fully. OSCEs requiring clinical signs, however, may need some
for synchronous distance learning using either Zoom® (Zoom creativity to be simulated. Various colleges also publish a rich
Video Communications, San Jose, California, USA) or in-­house variety of e-­learning modules which are examination oriented
software. These sessions are delivered across a variety of mobile and should be explored fully as form of asynchronous learning.
and computer platforms and presenters use voice-­over, screen This review of NUH’s teaching practice shows that innova-
sharing and recording functions to deliver synchronous and tion, with the use of technology, can adapt specialty training
asynchronous learning to STs on duty, at home or in commute. programmes in pandemics, although with modification and
It also allows for interactive engagement and collaboration and reduced frequency. While CME was initially disrupted as various
can be applied to tumour boards, journal clubs and case-­based training programmes adapted to a new segregated operating
discussions. Presenters can use interactive web-­based audience environment and developed new protocols, it was restarted
response systems for preteaching and post-­ teaching evalua- by most programmes by the fourth week. These virtual CME
tion and assessment through platforms such as Google Forms sessions have additional benefits of serving as a two-­way forum
(Alphabet, Mountain View, California, USA). The remaining for feedback from STs on the ground and for topical updates on
2 Kanneganti A, et al. Postgrad Med J 2020;0:1–3. doi:10.1136/postgradmedj-2020-137840

COVID-19 literature and protocols. STs will face increased stress
and fatigue as a result of increased workload and emotional toll
during this pandemic.12 Several STs have stated that regular
virtual CME sessions serve as a means of peer support and soli-
darity at a time of isolation and segregation. This likely helps
with individual coping mechanisms.
This pandemic is projected to last until the end of the year13.
We should adapt CME to a ‘new normal’ to keep our STs up to
date with their core clinical competencies and equipped to deal
with the full spectrum of clinical pathology that will no doubt
continue now and tomorrow.
List of learning points
►► The COVID-19 pandemic has caused disruption to continuing
medical education. Specialty trainees will continue to be
at the front lines looking after both COVID-19 and non-­
COVID-19 cases and they should be supported with training.
►► Specialty trainees should, and can, continue to receive
training with the use of distance learning technology such as
videoconferencing, archived videos, simulators and e-­learning
modules.
►► This pandemic may last until year’s end and Continuing
medical education should be adapted to the 'new normal' to
keep specialty trainees up to date.
Contributors AK, C-­HS and BA had equally contributed in conceiving and writing
this paper. BA and SB-­SO critically reviewed this manuscript. SB-­SO is the Designated
Institutional Official and oversees all specialty training programmes in the National
University Health System, Singapore.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Kanneganti A, et al. Postgrad Med J 2020;0:1–3. doi:10.1136/postgradmedj-2020-137840
Education and learning
Postgrad Med J: first published as 10.1136/postgradmedj-2020-137840 on 13 May 2020. Downloaded from http://pmj.bmj.com/ on May 13, 2020 at Uppsala Universitet BIBSAM Consortia.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
ORCID iDs
Abhiram Kanneganti http://​orcid.​org/​0000-​0002-​5559-​4534
Balakrishnan Ashokka http://​orcid.​org/​0000-​0001-​9175-​7479
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